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Get FL 749VMPR 2010-2024

A and (800) 447-3725 for Medicaid, Vista Medicare, Commercial, or Individual Members Priority: Stat (24 hours) Product: Commercial/Individual Urgent Emergent (72 hours) Medicare Routine Request (4-14 days) Medicaid PROVIDER INFORMATION PATIENT INFORMATION Name Name Address Member ID# City, Zip Code DOB Phone Healthy Kids Date of Request *Fax (Required to process authorization) Contact Person SERVICE REQUESTED: Fax Clinical / Plan of Treatment for Request Service Requested DOS.

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